ARISE: Addressing the Gaps in Asian American Health Research

August 24, 2023 - By Sarah Paris

Asian Americans, Native Hawaiians, and Pacific Islanders make up 7.7% of the U.S. population, yet historically, the National Institutes of Health invested a mere 0.17% of its budget to research the health of these groups. A large cohort study termed ARISE and led by Ann Hsing, PhD, professor of medicine, will be part of a national effort to address this gap.

“There has been a lack of research on Asian Americans because of a misconception that they are generally well-educated and healthy, compared to other minorities,” said Hsing. “While this may be partly true for some subgroups, Asian Americans, Native Hawaiians, and Pacific Islanders are highly diverse genetically, culturally, demographically, linguistically, and socioeconomically, with different health consequences.” She noted that even the term “Asian American” obscures the fact that it includes more than 40 heterogenous groups.

In March 2021, the National Heart, Lung, and Blood Institute (NHLBI) convened a multidisciplinary workshop, co-chaired by Hsing and by Alka Kanaya, MD, a professor of medicine at UC San Francisco. Two recurring themes emerged from the gathering: There is very limited data on the epidemiology, risk factors, and outcomes for these populations, and most existing data are not particular to each subgroup, which can mask variations in risk factors, diseases, and outcomes.

In their report from the workshop, published in the Annals of Internal Medicine, Hsing and co-authors from across the country concluded that the vast phenotypical differences among the subgroups provided an opportunity to inform prevention and intervention health strategies. The authors outlined a roadmap for research that included collaborations with community partners, investing in infrastructure for cohort studies, and incorporating digital technology to objectively capture health data during people’s daily lives. Gaining a deeper understanding of critical health factors in specific ethnic groups will provide a foundation for risk assessment, prediction, and culturally appropriate prevention strategies.

As a result of the report, the NHLBI set aside funding for a call to establish a large national cohort for Asian American prevention research. Stanford has been chosen as one of five study sites and has received funding to recruit 2,100 Asian Americans from the San Francisco Bay Area. In total, 10,000 Asian Americans, Native Hawaiians, and Pacific Islanders will be recruited across the country.

Because the Stanford cohort involves multiple endpoints, investigators include faculty from many divisions, departments, and other schools. In an exemplary team science effort, the study brings together epidemiologists, cardiologists, oncologists, psychologists, behavioral scientists, sleep medicine specialists, geneticists, basic scientists, as well as statisticians and technology experts.

“This will truly be a multidisciplinary and inherently collaborative study, bringing together colleagues with expertise in specialized areas who might not otherwise have had this terrific opportunity to work closely together toward a shared vision and goals under the leadership of Dr. Hsing,” said Clete Kushida, MD, PhD, professor of psychiatry and behavioral sciences and one of the co-investigators in the project.

The study will be a pioneering effort in a number of ways. It will be the first to:

  1. investigate the extent of chronic stress associated with immigration, acculturation and discrimination;
  2. study specific Asian American ethnic groups with in-depth cardiometabolic and cardiovascular phenotyping;
  3. capture extensive information on dimensions of well-being and assess their correlation with cardiometabolic and cardiovascular phenotypes;
  4. use a wearable monitor to assess heart rate variability, derive objective measures of stress and sleep structure, and detect sleep apnea using ECG signals; and
  5. contribute to a large biobank of specimens to perform integrative multi-omics, including oral and gut microbiome, and to assess correlations with well-being and cardiometabolic phenotypes.

“Chronic stress, particularly among immigrants, is something we have ignored for a long time,” said Hsing. “Immigrants are often under tremendous pressure to perform and to succeed by working harder than anyone else. On top of that, there is the stress of structural discrimination, something that has come into much sharper focus during the Covid pandemic.”

The research will include measuring the impact of nature on mental and physical health, using wearable technology to track peoples exposure to green and blue spaces.

“The pandemic drove home the profound dependence of people on nature experience for both mental and physical dimensions of well-being,” said Gretchen C. Daily, PhD, the Bing Professor of Environmental Science, and another one of Hsing’s collaborators.  “Yet, in the U.S., more than 90% of immigrants live in densely populated cities with very scarce and inequitable access to nature. Understanding and creating the opportunities that all kids and adults need for doses of nature – in the form of street trees, birdsong, flowing rivers, and urban parks – is a key advance that we aim to make together.”

Recruiting 2,100 participants for comprehensive data and biospecimen collection and clinical imaging is an ambitious goal. Yet Hsing is confident that it is achievable. Previous studies in smaller groups have shown that close collaboration with community leaders and clear communication on the goals of the research and its importance on the health of participants and future generations have greatly boosted enrollment.

Adding community engagement to a team science approach will ensure that novel discoveries are deployed to fill the most significant gaps in Asian American health research and minimize health inequities.

Learn more about DoM Team Science

Co-investigator and collaborators in the ARISE study will include:

CONTACT PI

Ann Hsing, PhD, MPH, Professor of Medicine (Stanford Prevention Research Center) and of Epidemiology & Population Health

MULTIPLE PIs

Clete Kushida, MD, PhD, Professor of Psychiatry and Behavioral Sciences, Division Chief and Medical Director of Stanford Sleep Medicine, and Director of the Stanford Center for Human Sleep Research

Paul Wang, MD, Professor of Medicine (Cardiovascular Medicine) and, by courtesy, of Bioengineering

Joseph Wu, MD, PhD, Professor of  Medicine (Cardiovascular Medicine) and of Radiology, Director of Stanford Cardiovascular Institute

CO-INVESTIGATORS

Ying Chen, PhD, Professor of Medicine (Stanford Prevention Research Center)

Victor Henderson, MD, MS, Professor of Epidemiology and Population Health and of Neurology

Esther John, PhD, MSPH, Professor of Epidemiology and Population Health and of Medicine (Oncology)

Ying Lu, PhD, Principal Biostatistician, Professor of Biomedical Data Science and of Epidemiology & Population Health

Kenneth Mahaffey, MD, Professor of  Medicine (Cardiovascular Medicine)

Mindie Nguyen, MD, MAS, Professor of Medicine (Gastroenterology and Hepatology) and, by courtesy, of Epidemiology & Population Health

Latha Palaniappan, MD, MS, Professor of Medicine (Cardiovascular Medicine) and, by courtesy, of Epidemiology & Population Health, Co-Founder and Co-Director of Stanford Center for Asian Health Research and Education

Sam So, MD, Professor of Surgery, Founder and Director of the Asian Liver Center

STANFORD SCIENTIFIC ADVISORY BOARD (SAB)

Kenneth Mahaffey, MD, Chair, Professor of Medicine  (Cardiovascular Medicine)

Euan Ashley, MD, PhD, Professor of Medicine (Cardiovascular Medicine), of Genetics, of Biomedical Data Science, and, by courtesy, of Pathology

Aya Kamaya, MD, Professor of Radiology (Body Imaging)

Bryant Lin, MD, MEng, Clinical Professor of Medicine (Primary Care and Population Health), Co-Founder and Co-Director of Stanford Center for Asian Health Research and Education

David Maron, MD, Professor of Medicine (Stanford Prevention Research Center)

Lorene Nelson, PhD, Associate Professor of Epidemiology & Population Health

Thomas Robinson, MD,  MPH, Professor of Child Health and of Medicine (Stanford Prevention Research Center), and, by courtesy, of Epidemiology & Population Health

Michael Snyder, PhD, Professor of Genetics

From the Department of Biology and the Nature Capital Project

Gretchen Daily, PhD, Professor of Environmental Science,  co-founder and faculty director of the Stanford Natural Capital Project (NatCap)

Anne Guerry, PhD, Lead Scientist at NatCap

Lisa Mandle, PhD, Lead Scientist at NatCap

EARLY-STAGE INVESTIGATORS

Shoa Clarke, MD, PhD, Instructor of Medicine (Cardiovascular Medicine) and of Pediatrics (Cardiology)

Mathew Kiang, ScD, MPH, Assistant Professor of Epidemiology & Population Health

Natalie Lui, MD, Assistant Professor of Cardiothoracic Surgery

In addition to Stanford, the sites for the national cohort study will include:

  • University of Hawaiʻi at Mānoa
  • University of Chicago
  • Fox Chase Cancer Center
  • New York University